Group Visits – An Ideal Mechanism for Enhanced Citizen Societal

Participation and Improved Personal Chronic Disease Control

Norbert Goldfield, M.D. Executive Director

Healing Across the Divides

Description of Group Visits

• A group-setting medical office visit that supports the patient receiving comprehensive medical care. The visit is structured to include education, clinical care and peer support.

• Visits may be one-time only, or patients may be part of a cohort that attends on a predetermined time interval (e.g., every 3 months).

• Groups are staffed by a combination of providers and staff appropriate to the purpose of the group visit, such as physicians, nursing staff (NP, RN, LPN, MA), care managers, clinical pharmacists, and representatives from other disciplines. These disciplines can also include community activists knowledgeable about the connection between society and chronic disease prevention and control.

Self-Management Goals• Identify self-management tools, including the

following:– an action plan that includes goals and describes behavior

(e.g., increasing activity by walking 15 minutes 3 times per week)

– A review of the patient’s personal barriers (e.g., too busy to exercise)

– Steps to overcome barriers– The patient’s confidence level (e.g., on a scale of 1 to 10,

how confident are you that you can meet your goals?)– follow-up plan

Purpose of Group Visits

• Increase patient empowerment – – Awareness of rights to appropriate care and – Enhanced patient dignity– Self-responsibility for best possible care of oneself– Increased empowerment at an individual, group and community

level

• Meet patient needs and provide quality care in a forum which:

• Leverages physician time• Maximizes skills of health care team• Improves or maintains patient and provider satisfaction

Types of Group Visits

• CHCC (Cooperative Health Care Clinic) Provides ongoing comprehensive medical care and education to a cohort of frail and pre-frail patients that meets monthly with their PCP.

• Disease-Specific Group Patients who share a medical condition meet for a one-time (or ongoing periodic meetings) with their PCP (or a clinic PCP) for clinical care and education.

• Disease-Specific Multi-Station Group Visit Patients who share a medical condition meet for a one-time (or ongoing periodic meetings) with their PCP (or a clinic PCP) for clinical care and education. There is a group education session at the beginning, then patients move among various stations addressing different foci of care (e.g., vital signs, medications, foot care, etc.).

cont

• DIGMA (Drop-In-Group Medical Appointment) A follow-up appointment conducted in a group setting with the assistance of a behavioral health specialist.

• Community Meeting to enhance appropriate services that can improve chronic disease control.

Another alternative to the group visit and the traditional one-on-one office visit is the high-flow clinic.

• High Flow Clinic Patients are scheduled for appointments on a short interval (e.g., every 5 minutes), and there is not a group component to the visit. Such clinics are typically held in a conference room with CIS stations. The clinic includes multiple stations hosted by an RN, mid-level and/or Clinical Pharmacist. Patients visit any one station and receive full care as per protocols/baselets. A physician is available for consultation, as needed.

Who attends group visits?

• Patients who have been invited to attend by their health care provider or nurse

• Patients who have diagnosis specific to the type of group offered

• Patients identified as needing regular follow-up care

• Patient referred by a community agency

Who should not attend group visits?

• Patients who refuse group visits

• Patients with physical or mental conditions that prevent them from functioning in a group appointment (e.g., hearing loss, memory loss)

How do patients benefit from group appointments?

• Receive education about a particular diagnosis

• Get disease-related questions answered

• Get health care needs addressed

• Get medications changed or refilled

• Receive support from others with the same diagnostic condition

How does the community benefit from group appointments?

• Increased communication between members of society with a particular chronic illness (such as diabetes and/or hypertension) leading to awareness of the different forces leading to challenges in chronic disease control and prevention such as:

Community benefit (cont)

– Economic forces: e.g. lack of access to appropriate medications

– Social forces e.g. lack of appropriate places of exercise

– Political forces e.g. conflict within low income populations and/or between populations leading to increased stress

– Cultural forces e.g. role of different types of foods which may be problematic in chronic disease control.

Who are the core staff for group visits and what are their roles?

• The physician provides education, evaluates specific disease indicators and consults on health care issues.

• The nurse and LPN/MA track attendance, collect patient evaluations, check vital signs, and provide other appropriate clinical care.

• The nutritionist provides input on appropriate foods• The clinical pharmacist evaluates medications and other

areas (e.g., BP and renal function).• The community health worker provides input on available

community resources and/or those needing improvement.

What types of outcome measures should be obtained to demonstrate

effectiveness of group visits?• Attendance• Show rates (number of patients who attend

divided by number of patients who had appointments)

• Patient satisfaction• Provider satisfaction• Disease management indicators as appropriate,

e.g. HbA1C, cholesterol, BP, foot care checks

Outcomes measures (cont)

• Measurable improvement in measures of empowerment of participating individuals

• Improved access to community services for participating individuals both from a medical (e.g. medication) and community (e.g. appropriate places to exercise)

• Increased citizen participation in community/societal issues that impact the management/ promotion of their chronic illness.

Pre-Work Questions

What is the need that you are trying to address?

• Community Specific:– Increased individual awareness of relationship between

community and their chronic illness– involvement in community issues pertaining to their chronic

illness.• Patient-specific

– Education– Hands-on clinical care– Medication review/adjustment– Convenient access

• Provider/Clinic-specific– Efficient use of human and other resources– Efficient flow of patients

How do you think you would like to address it?

• One-time group visit vs. periodic group visit– With same/similar cohort or not

• Multi-station vs. single station

• Education with group interaction

What roles will personnel play?

• Team lead• Coordinator/contact person• Liaison with the community• Recruiter• Greeter• Facilitator• Outcomes tracking• Attendance tracking• Clinical care• Education/counseling

What are the training needs and communication plan for staff and

physicians?

• For those directly involved in group visit

• For staff not directly involved in group visit (e.g., front desk staff, non-participating physicians and nursing staff)

What types of patients are eligible for the group?

• Diagnosis of particular disease/condition

• Specific age groups (e.g., elderly)

• Patients of a single physician or patients of a single department

• People from specific economic/cultural strata or across all strata

Diabetes Care Stations

Station 1: Foot Care

• Nurse examines feet

• Filament test done

• Nails and calluses trimmed as needed

• Education provided

• Care activities documented

Station 2: Community Health Worker

• Assessment of diabetes management and compliance

• Education on specific needs

• Care activities documented

• Discuss any economic/ social barriers to diabetes control

Station 3: Physician and/or Clinical Pharmacist

• Blood pressure and renal indicators evaluated

• Medication regime evaluated and modified using protocols

• Lab work ordered as needed

As you stop by each station, providers will check boxes below to indicate the appropriate

type of follow-up care for you Continue to take medications as you are now

Increase glyburide

Increase insulin

Follow up appointment with your physician

Follow up community activity pertaining to increased need for social services

Follow up appointment with community health worker

Foot Care Instructions

• Wash feet thoroughly every day.• Dry thoroughly, especially between toes. • Apply lotion to feet (but not between toes) after every

bath.• Exercise your legs daily to improve circulation and

muscles.• Inspect feet every day for reddened areas, sores, cracks.• NEVER GO BAREFOOT.• Cut toenails straight across, round the edges with an emery

board.

cont

• Call your doctor right away for any changes or problems you notice.

• Wear natural fiber socks.• New shoes? Wear only 2-3 hours a day to break them in.• Don’t ever use an electric heating pad on your feet.• Empty shoes of any small objects before putting them on.• Be careful where you walk. Turn on the lights at night to

avoid bumping you feet or toes.• Take you shoes and socks off at every doctor’s visit for

examination.

GROUP VISIT THEORY AND DESIGN

• Patients who attend group visits will receive diabetes care and engage in diabetes-related learning as an adjunct to their usual primary care. The group visits will last approximately two hours and will depart from traditional didactic diabetes education. They will evolve from patient experiences, guided discussions , and patient-identified goals, with the ultimate goal of improving self-management skills. By using participatory/adult learning theory we anticipate that group visits will be a collaborative process in which patients will engage in problem solving

• activities and gain decision-making as well as information-seeking skills. While the curriculum includes topics and objectives that will likely be addressed in each session, patients will set or alter the suggested agenda.

• Each group visit will involve 2 core health providers ( a bilingual physician or nurse practitioner and bilingual health educator), 15 patients, and occasional guest facilitators if patients request their presence (e.g. a nutritionist, or physical therapist). A bilingual pharmacist will be available at the close of each session to review medication adherence and any changes in regiment. The structure of the groups will be as follows:– Check in– Empowerment based adult learning– Break-out with individual providers– Wrap-up

Check-in

• 30 minutes.

• Patients describe any symptoms, needs, and their progress/obstacles in reaching goals. This is the time when action plans are discussed.

Empowerment-based Adult Learning

• 45 minutes.

• The Group reflects on a topic selected the previous month or during check-in. Facilitators guide a group learning session that includes relating and reflecting on experience; exploring and problem-solving; and taking thoughtful action. Patients help and teach each other.

Break Out With Individual Providers

• 30 minutes.• Patients who request or have been identified (during

check-in o9r break) as needing more care will received individual time for exams and tests (physician or NP), medication counseling and prescriptions (pharmacist), or health education (health educator). Each patient for whom a billing sheet is submitted by the physician or nurse practitioner must have a one-o-one encounter with that provider. That will usually occur during this part of the group visit. Patients who aren’t meeting with the facilitators will use this time for a break, healthy snack and socializing.

Wrap-Up

• (15 minutes)

• A final reconvening. Prescription printouts will be distributed and topics or “homework” for the next session will be discussed. This will also be the time to readdress the action plans and ask if anyone wants to change their action plan based on the topic discussed during that session.

Create a psychologically safe (accepting, uncritical) environment for personal

reflection and sharing:• Avoid giving advice

• Accept, acknowledge and avoid attempts to change participant’s feelings about or perceptions of their experience

– Listen actively: use body language, acknowledge and affirm during the discussion

– Emphasize confidentiality of group discussions

– Model storytelling-share personal stories to illustrate points

– Provide positive feedback when possible

Communicate Effectively:Clarify ideas within the group to foster

dialogue, learning and decision-making.• Repeat remarks made by various speakers.• Define ambiguous words or ask the group to

define them.• When it is not necessary for you to answer a

question asked, throw it back at the group.• Ask participants for suggestions on how the

discussion should continue, and present a few ideas based on observations of how the dialogue is progressing.

•Keep the conversation on track by asking “why” and “how” questions.

•Summarize the ideas mentioned and the sequence in which they were made. Announce observations you made about the group dynamic. Keep these comments short and constructive without focusing only on the negative.

Accept Your Role As a Provider, Educator or Facilitator, Not Group

Therapist.• You are there to guide the groups and encourage

participants, not to solve every participant’s problems. Although each facilitator brings different life experiences and professional skills that enhance the project, keep in mind interpersonal communication skills, sensitivity, patience, warmth, openness, and respect while conducting this program. Also, use neutral verbal and body language - your comments should not influence a group’s decision-making process.

Balance the needs of verbal and reticent group members

• Ensure that every participant has an opportunity to speak. Balance the needs of verbal and non-verbal group members by asking open-ended questions. Depending on the group you facilitate, a few rules on speaking order might be helpful. For example every participant must make a comment about the topic discussed, how they feel, or any challenges they have encountered, before any participant can make a second comment.

Foster Understanding

• In spite of disagreements within the group, you must encourage participants to understand (not necessarily agree with) differering points of view; highlight agreements made and point out differences. This is the only way a productive discussion can take place.

Provide Significant Others or Family Members With an Opportunity to Express Opinions or Concerns:

• Occasionally family or friends will accompany a patient – Comments made by such family members or friends can be helpful to the discussion and can bring up issues that can help a patient better manage his/her diabetes. However, at times tensions rise between participants and their partners due to such comments.

Guide Discussions to Stay Focused on Course Objective:

• To increase the exchange of ideas and communication within the group, in addition to personal experiences, suggest other methods of discussion: brainstorming, small group/large group discussions, writing, performing, flip chart, or silent reflection. The goal is to increase participants’ self-awareness, foster skills such as goal setting, and to enable them to plan and carry out self-directed behavior changes.

The Ideall Clinician Should:• Stay behind to talk to participants. In most sessions

there will be at least one participant who will want to ask additional questions, need additional clinical care, or who just wants to talk. Make yourself available to such patients.

• Check-in with your co-facilitator and other health team members. Discuss how the group visit progressed and any concerns you might have.

• Write a progress note for each patient. The notes should be written by the IDEALL clinician, with input from the Health Educator. If the pharmacist completes an individual consultation with a patient, s/he should write a separate note, on the pharmacy progress note.

Nurse Practitioner/Medical Exam Assistant:

• Measure and document patients’ blood pressure, blood sugar ( if indicated), and weight. Also perform and document pain assessment.

• Perform medical examinations. Perform medical examinations for individual patients when needed. (NP only)

• Give vaccines as needed.• Perform post-visit examinations. Perform post-visit

examinations. Perform post-visit examination duties.• Explain medical examination procedures to patients• Perform medical data entry retrieval duties• Prepare for and instruct patients about specific diagnostic

and therapeutic procedures.

Complete an Encounter Form for each Patient

• Providers can bill for their encounters as long as the have a one-on-one encounter with the patient.

• If a regular exam room is needed for private visits with patients after the group visit, look for an available one outside of the conference room.

• Make patient follow up calls as needed.

The Health Educator should:

• Stay behind to talk to participants. In most sessions there will be at least one participant who will want to ask additional questions or who just wants to talk. Make yourself available to such patients.

• Check –in with your co-facilitator and other health team members. Discuss how the group visit progressed and any concerns you might have.

• Complete a quality of interaction questionnaire. This should be a joint effort between both facilitators. The forms will include a section on facilitator self-assessment, as well as a joint assessment of the group visit as a whole.

Pharmacist:• Session 1. The pharmacist will be present during the entire

session to meet the group and introduce the concept that a pharmacist will be available at the end of subsequent sessions to answer questions and discuss concerns.

• Sessions 2 – 9 Pharmacist should be available the last 30 minutes (during the break/wrap-up portion of the session) to consult with individual patients.

• Conducts a one on one medication history interview with every patient at least once during the 9 month program.

• Assist in the generation of new prescriptions. All written prescriptions will have to be cosigned by a CHN provider.

Pharmacist Continued

• Provide counseling and education for ANY medication changes made during the group visit.

• Update the LCE with all medication changes/additions – a computer will be available outside the room where the visits will be held

• Document all patient encounters on the IDEALL Pharmacist documentation form.

• Review and clarify prescription medication schedules (using charts, calendars, other visuals

• Make OTC recommendations as needed• Provide counseling/education for alternative medications.

Brainstorming with Group Members

• The purpose of a brainstorm is to collectively and creatively generate as many ideas on a topic as possible WITHOUT any self editing . The editing and use of the ideas generated in a brainstorm come AFTER the brainstorm is over. Quantity of ideas during a brainstorm is more important than quality. However, think about your purpose for the brainstorm – do you just want people to begin thinking about a particular theme? In that case, writing up all the ideas may not be necessary. Do you want people to generate ideas that may be used for problem-solving later? In that case a written record of what they said may be very necessary.

Procedure:• One leader writes topic/question on flip chart or board.• Other leader invites participants to brainstorm (read top9c/question

from chart/board).• One leader writes ideas as they are called out while the other leader

looks at class and encourages flow of ideas. This is done by body language, (looking a t participants, nodding, opening eyes wide, etc., not verbally.

• If an ideas is long or unclear the leader who is soliciting responses should ask participant who offered the ideas to paraphrase it. If participant is unable to do so, leader should paraphrase it and ask participant if it is acceptable phrased that way. If so, write it on the chart/board.

• Leaders should make no comment when ideas are flowing. However, sometimes at the beginning of a brainstorm,participants are often shy

Procedure (cont)

• to voice ideas so a few words of encouragement (such as, “yes, now you’ve got the idea, etc”) will encourage participation.

• Once you have made your list of possible solutions or recommendations through brainstorming discuss the importance and possibility of each suggestion and PRIORITIZE them.

Cardinal Rules for the Scribe

• Do write down EXACTLY what people say. VERBATIM.

• Don’t paraphrase or rephrase what people say.

• DO acknowledge every idea.

• DON’T ignore or discount any ideas.

Introduction

• Introduction to staff.• How long have you had diabetes?/How has Diabetes

affected your life?• Patient introduction• Allow patients to share common experiences• Assess what kind of experiences patients bring to the

groups• Demonstrate diabetes affects everyone in the family• Group guidelines• Discuss basic guidelines

Introduction Continued

• Initiate ongoing process for guidelines reevaluation

• Ensure patients feel comfortable sharing personal information/stories

• Elicit patient input for curriculum topics*• Motivate patients to participate in subsequent

group visits• Highlight (something new/good) from the session.

Glucose Monitoring and Initiating Exercise

• Self-blood glucose monitoring• Review proper self-blood glucose testing (including tools used) – ask

patients to demonstrate • Convey importance of glucose monitoring• Review when and how often glucose monitoring should be done• Exercise• Assess-what are patients doing already?• Discuss successful exercise habits and possible barriers to exercising• Address- Why is exercise important for patients with diabetes?• Elicit patient participation via facilitating questions• Include a short demonstration on 2-3 exercise options• Discuss individual goal-setting for daily/weekly exercise goals• Recommend exercise options• Highlight (something new/good) from the session

Exercise & Relaxation• Introduce “keeping track of your own progress” and family

involvement as well• Review exercise goals from previous month• Address continuing challenges with exercise and how to

overcome them• Where to exercise in your neighborhood?• Offer possible safe options • Highlight (something new/good) from the session• Relaxation• Lead a group relaxation exercise• Elicit alternate exercise/relaxation techniques from

individual patients.

Nutrition/Diet Basics• Recommendations for a general healthy diet• Food groups/Food pyramid• Introduce the various food groups• Initiate discussion on healthy eating• Assess diet trends among group• Aid patients in becoming aware of their own eating habits• Demonstration of portion sizes• Utilize food models and/or hands• Ensure patients understand appropriate food portions• How to plan meals• Use Plate (or Bowl) Model• Discuss how patients will implement changes to their diets on a daily basis• Convey importance of changing little by little and not all at once• Highlight (something new/good) from the session

Nutrition/Diet Basics• Recommendations for a general healthy diet• Food groups/Food pyramid• Introduce the various food groups• Initiate discussion on healthy eating• Assess diet trends among group• Aid patients in becoming aware of their own eating habits• Demonstration of portion sizes• Utilize food models and/or hands• Ensure patients understand appropriate food portions• How to plan meals• Use Plate (or Bowl) Model• Discuss how patients will implement changes to their diets on a daily basis• Convey importance of changing little by little and not all at once• Highlight (something new/good) from the session

Nutrition Demonstration

• (Family members included)Clarification of what starches areRecommended total intakeReading food labelsEnsure that patients and/or family members know the basics of reading food labelsEncourage patients to demonstrate/explain to othersCooking demonstration or mock supermarket tripWhere to shop in your neighborhood to get fresh//healthy food:Diabetes affects the entire family”Encourage family members to support patientsFacilitate communication among family members to work on healthy mealsHighlight (something new/good) from the session

Monitoring Medications• Reasons for missing/skipping medications• Techniques on how to remember or how to make pill taking easier• Address/discuss barriers to adherence• Allow patients to share how they feel about medications and to

suggest ways in which other patients can be more adherent.• What to do if you missed a dose?• Convey that group visits are not meant to be accusatory• Ensure patients understand importance of not skipping medication

doses• Ensure patients know the appropriate people/places to call if they have

questions and/or have problems with their medication or refills• Scheduling – what works for you?• Facilitate small brainstorming sessions among patients to generate

some ideas• Highlight (something new/good) from the session

Foot Care

• Ensure patients know that food problems are associated with diabetes

• Convey importance of checking one’s feet daily

• What to look for

• Ensure patients know about nail/skin care

• Recommendations on products and where to get them

• What to avoid i.e. walking barefoot, tight shoes

• What to do if patients has a problems

• Highlight (something new/good) from the session

Risk Reduction/Access to Care

• Controlling your Blood Pressure• Ensure patients know what high/low blood pressure symptoms feel like• Discuss complications of blood pressure• What can be done to lower blood pressure if high• Convey the relation between blood pressure and Diabetes• Smoking• Reiterate knowledge on harmful effects of smoking• Discuss complication related to Diabetes• Provide information and support for those who are interested in quitting• Appointments• Reminder of upcoming appointments• If applicable, where they should go for their appointments and/or how

to to get there

Risk Reduction-Access to Carecontinued

• Discuss recommended visits to a primary care provider, ophthalmologist, nutritionist, etc.

• Highlight (something new/good) from the session

• Sick care: when to call your clinic, when to call 911, when to limit activity.

Minimum Ground Rules

• Come to sessions on time• Do not interrupt others• No side conversations: please let other patients share their

experiences completely• Confidentiality – I.e. “You are free to talk to others about what

you learned in the groups, but do not mention the names of the people who are in the group.”

• Call your facilitators throughout the month if you have any questions before your next group visit.

• Don’t tell others “you should…”• Instead of saying “I will TRY to do something” think about

saying “I WILL do something.”

Action Plans• Although it may not be explicitly mentioned in each individual

protocol, one of our primary objectives is to encourage patients to generate their own goals. Some patients will be more motivated and confident about their ability to carry out their goal, while others will need additional support. The definition of a “goal” should be flexible. Anything from eating 3 tortillas less a week, to checking their blood sugar 2 times per week, to walking everyday for 30 minutes, should be encouraged. Patients should not be coerced into making a goal that the provider or health educator thinks is important or necessary. Although the provider or health educator may advise a patient as to what could be prioritized, the final goal should be set BY THE PATIENT, and should be something that he/she is interested in doing and thinks he/she can achieve.

• The focus is also to engage patients and work in a stepwise manner towards long-term changes to their health. Hence, short-term and long-term goals should be set. Patients should be engaged in problem-solving and decision making throughout the intervention. As mentioned before, the goal should be focused on the ongoing process rather than the immediate “quick fixes.”

• While working with patients to set goals, providers and health educators should use positive feedback wherever possible. Even if patient does not achieve his/her desired goal for the week/month, he/she is NOT a failure. If a patient cannot carry out his/her goals, this is the time to reassess the goals made, find out what barriers prevented the patient from completing his/her goal, and reframe the goal or task at hand. Help patient either work on a new goal, or change the past goal into something more attainable.

ACTION PLANS – SAMPLE SESSION

• Goals are generally too big to work on all at once. Therefore, we need to start one step at a time and with smaller goals. For example, if my goal is to lose weight, I might start with deciding what type of exercise to do, then where I can go to exercise, how much time I will spend exercising when first starting, and maybe asking a friend or family member to exercise with me.

• Next facilitators would lead participants into the next activity – deciding what goal or action plan to make this month and how we are going to do it. (You can either write these down on the board, or simply remember to ask these in series when helping patients formulate their action plans.)

Parts of an Action Plan• 1. Something YOU want to do – not what your doctor, nurse, family, or

anyone else thinks you should do• 2. Realistic – something you think you can REALLY do this month• 3. A specific action – for example, losing weight is not specific, but

not eating chips or other snacks between meals IS• 4. Answer the questions:

• What? – for example, eating more vegetables• How much? – For example, 1 extra cup a day• When? – for example, with dinner• How often? – For example, 4 times a week• Confidence level of 7 or more – In other words, HOW SURE

ARE YOU THAT YOU WILL BE ABLE TO DO THIS ACTION/PLAN/GOAL

• 0=don’t think you can do it to 10=you definitely think you will complete the action plan.

Avoid Large Technical WordsAppendix A

Effective clinician-patient communication has been linked with improved patient comprehension, recall, satisfaction and health outcomes. Successful communication, in part, requires that participants draw from a more or less common vocabulary and experience. This may be especially important for patients with barriers to communication, such as those with limited health literacy (HL)

cont

In a recent study conducted at San Francisco General Hospital, physicians caring for patients with limited HL and Type 2 Diabetes used at least one unclarified jargon term in the overwhelming majority of visits, often in the context of carrying out important functions of the medical encounter, such as providing recommendations and/or health education.

There may be several reasons why physicians employ jargon in their

interactions with patients 1. Physicians are trained and function in a context, often

referred to as the :”culture of medicine”, that values the efficient transmission of highly technical information;

2. Physicians may be unaware of the degree to which the language they use in the professional/collegial context permeates their discourse with patients, or they may over-estimate the degree to which their patients understand such terminology:

cont

3. Physicians may be employing unclarified jargon to assert their professionalism or in contrast, to “empower” patients by exposing them to concepts and terms critical to patients’ self-management.

Words from Big Word Study

(test) strips Hba1c

Bypass Heart failure

Constipation Kidney function

Diagnose Micro-vascular complications

Dialysis Pattern of blood sugar

small bowel obstruction

References

• Noffisinger, E. B. , Scott J. (2000). Practical Tips for Establishing Success Group Visit Programs. Group Practice Journal, 49(6), 31-36

• Osborne H. (2001). Changing Behaviors. In Partnering with Patients to Improve Health Outcomes. Gaithersburg, MD: Aspen Publishers

• Osborne H. (2001). People Who Speak Little Or No English. In Overcoming Communication Barriers in Patient Education (pp. 37-51). Gaithersburg, MD: Aspen Publishers

• Schillinger D., Piette J., Grumbach K., Wang F., Wilson C., et al. (2003) Closing the Loop: Physician Communication With Diabetic Patients Who have Low Health Literacy. Archives of Internal Medicine, 163: 83-90